Clinician Alert Updated Interim Guidance for hMPXV (Monkeypox) September 2, 2022

September 2, 2022

Key points:

Health care providers should have a low threshold for testing patients with rash illnesses for hMPXV. (See: Testing) Billing and coding details here for OHP patients.
Testing is available via routine lab channels without approval from local or state public health. Every clinical site can and should swab lesions and submit specimens as they would for many other infections. (See: Evaluate and Test Patients on Site)
Treatment with hMPXV-specific medications may be indicated for high risk individuals and those with severe or very painful infection. (See: Treatment)
Vaccine is available for post-exposure prophylaxis and high risk individuals. Default vaccination administration route is intradermal for adults. (See: Vaccines)
For possible, presumptive or confirmed cases, providers should offer supportive care and basic education about isolation practices: staying home whenever possible. Masking and keeping lesions covered when leaving home when necessary. (See: Patient Education)

Summary

Community transmission of hMPXV (monkeypox) is ongoing in Oregon, with over a hundred cases in the Portland metro area. Cases have been identified in every US state.

Transmission primarily involves intimate, skin-to-skin contact with the rash of an ill person, mostly within social networks of men who have sex with men (MSM). Having multiple sexual partners increases risk. The infection is not thought to be a sexually transmitted disease per se and can affect anyone.

Risk to the broader public is still considered to be low at this time, but we continue to watch transmission trends for changes. Clinicians should remain alert to hMPXV in any patient with compatible symptoms, and should test for both hMPXV and any other suspected conditions.

Transmission

Sexual and other intimate contact is a known source of transmission for the majority of current cases, and can cause oral, anal, and genital lesions that may lead individuals to present to STD and HIV clinics or other STD testing programs.

While transmission via contaminated materials such as bedding or towels and by respiratory spread via large droplets is possible, these routes of infection have generally not been observed in the current outbreak.

Symptoms and incubation period

Current cases have presented in a variety of ways both with and without prodromal symptoms. Nearly all cases have a rash or mucosal lesions, and most have fever. Surveillance studies have shown some individuals with essentially asymptomatic rectal or oral infection. Prodromal symptoms, if present, typically start 1-3 days before development of the rash and can include fever, chills, fatigue, malaise, headache, and swollen lymph nodes.

The rash may be painful or itchy. Lesions can start with macules that progress to papules, then firm, well-circumscribed, fluid-filled vesicles and/or pustules over the course of 2-3 weeks. Some patients initially present with a papular rash. The lesions may umbilicate or ulcerate and may be deep seated. Skin and mucus membrane lesions may involve any part of the body including the mouth, palms and soles, and anogenital areas.

The incubation period (time from exposure to symptoms) for hMPXV is typically 5-14 days, but can range from 4-21 days. Recent case series suggest that the incubation period in the current outbreak is about 5-7 days.

While skin lesions can be painful and subject to secondary infection, most individuals recover in 2-4 weeks without treatment beyond supportive care. Information about treatment options and which patients may need treatment can be found here.

Testing

We are asking clinicians to

Consider monkeypox as a possible diagnosis for anyone with a compatible clinical presentation, especially in the setting of intimate or other skin-to-skin contact with an individual known or suspected to have monkeypox (similar rash) or with other risk markers.
Entertain the possibility of hMPXV even with an atypical rash (especially in the context of epidemiologic risk factors). Testing can be done concurrently with tests for other conditions.
Test for other diseases as appropriate, including but not limited to syphilis (very common), herpes, shingles, molluscum contagiosum, chancroid, varicella, lymphogranuloma venereum, granuloma inguinale, folliculitis. In children, hand foot and mouth disease can look similar. Keep in mind that Orthopox can present concurrently with another diagnosis, including HIV.
Take advantage of the interaction (if appropriate for the context) by doing full STI screening (GC/CT, syphilis, HIV, hepatitis B and C) and discussing HIV PrEP.
Gather current and emergency contact information for patients and advise self-isolation until lab results are back and negative, or if positive, when the rash is completely healed. A one-page document outlining home isolation is available here. Please share it with patients who are being tested for hMPXV.
If test results are positive for a patient with atypical clinical presentation and no epidemiologic risk factors, consider requesting that the lab re-test the specimen. While highly sensitive, current PCR tests have resulted in rare false positives (likely from contamination from positive samples), typically with a cycle threshold (CT) value of 34 or higher. See more here. Patients should continue to isolate until subsequent results are back, but can discontinue isolation and should be considered hMPXV negative if the second test result is negative.

Case definitions and further clinical considerations for determining need for testing can be found here.

Evaluate and test patients on site

There are no dedicated orthopox evaluation/testing sites in our area at this time; healthcare providers should evaluate patients on-site. Testing supplies and PPE required for hMPXV testing are widely available, and essentially all healthcare settings can provide this care to patients. There are now several commercial laboratory testing options for Orthopoxvirus and approval from state or local public health is not required.

Patients in need of testing who have no medical home or other access to testing may be seen at the Multnomah County Health Department STD clinic. Appointment availability is limited, and individuals seeking testing must notify schedulers when calling that they need to be seen for hMPXV (Orthopox, monkeypox) testing.

Turnaround times for results is ideally 2-3 days, but may be longer with high volumes and depending on transit time. Patients who tests positive may receive their results from local public health contact investigators before you are able to provide results.

Sample collection

Collection logistics vary slightly by laboratory, but for all laboratories:

Collect vigorous swabs of skin lesions with a sterile polyester or Dacron-tipped swab. If a pustular or vesicular lesion is unroofed, be sure to collect fluid from the lesion, but unroofing a lesion is not necessary.
Place each swab (if more than 1) into separate 1.5-2 mL screw-top sterile containers. Commercial labs request universal or viral transport media; OSPHL requests dry swabs without media.
Label each container clearly with the specimen site.
See further specimen collection, storage, and shipping information for:
- Oregon State Public Health Lab (available if other labs are not an option)
- QUEST
- Labcorp
- Mayo (see CDC collection information)
- Sonic (see CDC collection information)
- Aegis
- ARUP
Store specimens refrigerated per OHA guidance.

Patient history

If you suspect hMPXV, ask for:

A brief sexual history. If the person tests positive, public health will inquire about number and timing of partners, use of apps to meet partners, attendance of bathhouses or sex clubs, any anonymous partners, etc.
Date of onset of symptoms, which symptoms are present, and for a rash, what parts of the body are affected.
Relevant conditions (immune compromise, pregnancy or HIV)
Verify:
- race/ethnicity, gender identity and sexual orientation
- county of residence and other contact information

Advise patients on isolation and contact tracing

Advise patient to isolate at home until results are back, typically in 3-6 days, and provide instructions for the individual being tested and for those they live with (both available in additional languages here).
Advise them to make a list of individuals they have spent time with / had contact with since the onset of symptoms. Let them know that if the result is positive, a public health contact tracer will reach out to them and review these details to help determine if anyone is eligible for post-exposure prophylaxis. Local public health will also help ensure they have the support needed to isolate safely.

Treatment

Follow-up with positive patients regularly to determine if they need symptom relief and to assess for severe or complex infection that may need further treatment.

If you believe treatment is indicated for a patient with hMPXV infection based on severity of infection, presence of complications, or high-risk factors (immune compromise, pregnancy, age 8 or younger, or those with active, exfoliative skin conditions such as atopic dermatitis) and you do not have access through your health system pharmacy, you may consult with the OHA state epidemiologist on-call at 971-673-1111. Examples of complicated or severe infections include those with bronchopneumonia, secondary bacterial infections, atypical infection sites such as eyes or anus, hemorrhagic disease, sepsis, encephalitis, severe pain, or other indication for hospitalization. See current CDC indications for tecomirivat use here.

Guidance for supportive care and information about obtaining and providing hMPXV-specific treatments are available. Several treatment options are available for high risk or severely affected patients. The most common is Tecovirimat:

Tecovirimat

Tecovirimat (brand name TPOXX) is an oral antiviral therapy with activity against smallpox and monkeypox. It is FDA approved for smallpox and now available for hMPXV patients with severe or very painful infection or those at high risk for unfavorable outcome. Data regarding use in humans is just emerging. A research letter published 8/22/22 described its use in 25 patients. It was generally well tolerated with resolution of lesions and pain in 92% of participants by 21 days. However there was no control arm, so interpretation of efficacy is not possible. The link for the Tecovirimat OHA Request Form can be found on this page.

Vaccine

At present in Oregon, vaccine is available for those requiring PEP (post-exposure prophylaxis) and as PreP (pre-exposure prophylaxis) for individuals who meet other high risk criteria. PEP with JYNNEOS vaccine is available in every county for high and intermediate risk contacts to individuals with hMPXV, including occupational exposures, if the exposure happened less than 14 days prior. The sooner PEP is administered (ideally within 4 days of exposure) the more effective it is at preventing infection/severe infection.

Screening, authorization, and scheduling for PEP can be done directly by the health department for the county of residence of the exposed individual (see contact information for each health department below).

Individuals needing vaccine after exposure (PEP) should call / email the communicable disease team for their county of residence ASAP.

Individuals wanting to schedule an appointment for a PreP vaccine based on the OHA risk categories (other than post exposure prophylaxis) should call 503-988-8939. Vaccines are currently scheduled within a week and there are vaccine sites all over the tri county region. Vaccine is available from OHA to provide as PrEP to your high risk patients.

The vaccine strategy for addressing this outbreak will continue to evolve as more cases are identified and as more vaccine becomes available from national stockpiles.

Infection prevention in clinic or hospital settings

Notify and consult with your organization’s infection preventionist regarding any positive or suspected cases. Ensure that you have a mechanism for tracking which staff have interactions with potentially infectious patients. Consult occupational health for any potential staff exposures meeting high or intermediate risk.

In the clinic or hospital setting, implement standard infection control precautions, including but not limited to:

Mask all patients with a febrile or rash illness as source control, preferably with a procedural mask or KN95 mask.
For patients with visible lesions on the body, provide a gown or dressing to cover lesions
For clinicians and staff: If monkeypox is suspected, all staff interacting directly with the patient should use gloves, gown, NIOSH-approved N95 respirator or higher level of protection, and eye protection. Notify your infection prevention and control personnel immediately. If possible, exclude pregnant and/or immune-compromised staff from interaction with individuals with suspected hMPXV.
Limit time spent by suspect hMPXV patients in a waiting room or other parts of the clinic and keep the room door closed as much as possible. Handle laundry and PPE carefully including disposal of any PPE or dressings in biohazard containers, routine disinfection of surfaces and careful handling of patient-used laundry. Activities that could resuspend dried material from lesions, e.g., use of portable fans, dry dusting, sweeping, or vacuuming should be avoided. Negative pressure rooms are not required for evaluation of individuals with suspected hMPXV.
See further information regarding infection prevention in clinical settings here.

Patient education

With symptoms

Educate patients presenting with symptoms concerning for hMPXV on home isolation precautions. (available in other languages on OHA site)

They should isolate at home and away from other household members until results are back.
They should keep lesions covered. If this is not possible due to the extent or severity of the rash, they should restrict themselves to a single room if possible. A surgical mask or greater respiratory protection should be used at all times by infected individuals when they must share space with others, especially when respiratory symptoms are present.
Family members, housemates, and pets should avoid contact as much as possible, and unexposed individuals should not visit the home.
Contaminated waste (such as wound dressings) must be handled and disposed of carefully. See waste disposal guidance here.
If test is positive, patients must continue isolation until the rash has resolved and all scabs have fallen off (usually 2-4 weeks). The local public health department may be able to provide support to individuals needing to isolate.
If some of these precautions cannot be fully implemented (e.g. the patient cannot completely isolate for the entire duration of rash), CDC does include some guidance to mitigate risk of spread to others.

Exposed

For individuals exposed to a confirmed or probable monkeypox case:

Direct them to their local public health department to discuss post-exposure prophylaxis (PEP, see above). Vaccination is most effective in the four days after exposure, but may have some benefit for up to 14 days and before rash or lesion eruption.
They are not required to quarantine, but should watch for signs and symptoms of hMPXV infection, and are encouraged to monitor for onset of fever with twice daily temperature measurement until 21 days from the last known exposure. The local public health agency will be in contact with any identified individuals meeting intermediate or high-risk exposure criteria. The CDC provides further guidance for symptom monitoring in exposed individuals here.
Individuals with known exposure should strongly consider avoiding any group event or anonymous interaction expected to include sexual or other skin-to-skin contact until 21 days from the last known exposure. In general, limiting the number of intimate contacts / condom use during the current outbreak will help lower risk of disease transmission.They should also avoid donating blood, tissue, breast milk, semen or organs until through the 21 day observation period. Individuals with high risk exposure and those in isolation who had a high risk exposure are also discouraged from travel by public transportation (plane, train, bus).

Not currently suspected of having hMPXV

For individuals who are not currently suspected of having hMPXV: educate at-risk patients/clients about risk factors, common symptoms, and strategies to reduce risk of hMPXV infection or exposure, including:

Encouraging individuals to be vaccinated if they meet current OHA criteria
- Vaccine specifics (number of doses, age restrictions, administration route, contraindications/precautions, where folks should call to be screened/scheduled if no access through clinic/health system)
Encouraging individuals to abstain from sex/close contact with others if they develop a new skin lesions or otherwise suspect they may have hMPXV (such as prodromal symptoms and risk factors for acquiring hMPXV). They should isolate and consult with a clinician to determine need for testing if they develop symptoms
If individuals identify as having had close contact with a known or probable hMPXV case, direct them to their local public health department at the below contacts. See below for further guidance
Condoms may reduce risk if hMPXV sores are limited to penis/rectum/vagina, but should not be relied on to prevent transmission of hMPXV as there may be rash elsewhere on the body. Condom use may have increasing value if reports of asymptomatic rectal hMPXV infection are born out by further study.
Limiting number of intimate contacts will decrease the risk of acquiring infection during the current outbreak

More Information

The current circulating virus is a known hMPXV virus strain from Western Africa, and is considered to be a milder form. Severe outcomes such as bronchopneumonia, sepsis, encephalitis, and corneal infection with vision loss are possible but uncommon, and the WHO estimates mortality from hMPXV at 3-6%. Severe outcomes are thought to be more common in those with immune compromise, in children, in pregnant people, and in individuals with eczema and other exfoliative dermatologic conditions. There have been few hospitalizations and 15 deaths to date with the current identified cases in this outbreak worldwide. As of late August, there has been one presumed hMPXV-related death in the US.

Unlike COVID-19, individuals with hMPXV are thought to only be infectious while symptomatic. Evolving data suggests there may be more subclinical infection than previously recognized - specifically nonpainful lesions in the rectum and mouth. Individuals with confirmed or suspected monkeypox should isolate until the rash has resolved (scabs gone) except to seek testing and/or medical care. Most individuals recover spontaneously in 2-4 weeks without treatment.

Communicable disease program contact information

Clackamas County Public Health: 503-655-8411 (PEP requests may be emailed to PH-IDCP@clackamas.us)
Multnomah County Health Department: 503-988-3406 (choose option 3 after hours for urgent needs)
Washington County Public Health Division: 503-846-3594 (PEP requests may be emailed to HHS_PublicHealth_DCAP@co.washington.or.us)